In real-time records of three million attacks, eletriptan emerged as the most effective among 25 of the most commonly used acute migraine medications across seven pharmacological classes.

Numerous medications have shown efficacy for acute treatment of migraine. However, studies directly comparing these medications remain sparse, were small and measured only single-attack efficacy. In this study, researchers leveraged real-world health data from 278,006 patients via a smart-phone headache diary application, analysing 3,119,517 migraine attacks to produce a comprehensive direct comparison of 25 of the most commonly used acute migraine medications across seven pharmacological classes. Medications included paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), combined paracetamol/acetylsalicylic acid/caffeine, antiemetics, opioids, ergots and triptans. Among 34% of patients with available data, 90.7% were women, and mean ages were 37.8 years for men and 35.9 years for women. Most were from the USA (71%), the UK (11%) and Canada (7%).

Most patients chose one acute medication (65.5%) to relieve a migraine attack, rather than two (23.3%), three (7.2%) four (2.4%), or five or more (1.6%). Ibuprofen was the most frequently used medication, followed by sumatriptan and paracetamol. Just over half of the patients reported their medication as ‘helpful’ and 19% as ‘unhelpful.’ Triptans had the highest percentages of reported positive treatment outcomes, with eletriptan ranked the best (77.9%), followed by zolmitriptan, sumatriptan and rizatriptan. Frovatriptan was ranked the least effective triptan; however, patients still preferred it over medications in other pharmacological classes. Following triptans, in descending order of helpfulness, were ergots, antiemetics and opioids. Despite its common first-line recommendation, paracetamol had the fewest positive treatment outcomes (37.7%). UK users reported triptans as more helpful than did other users, whereas USA users rated codeine more favourably, suggesting different perceived effectiveness.

Comment: In this real-world analysis, patients rated triptans the most effective treatment for acute migraine, followed by ergots and antiemetics. Among individual medications, eletriptan ranked the most effective and paracetamol the worst. In clinical practice, physicians should recommend triptans as a first-line medication for acute migraine instead of paracetamol and NSAIDs to prevent delayed treatment.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Robyn-Jenia Wilcha, MD, Physician, NIHR King’s Clinical Research Facility; SLaM Biomedical Research Centre; and Wolfson Sensory, Pain and Regeneration Centre, King’s College London, UK.

Chiang C-C, et al. Simultaneous comparisons of 25 acute migraine medications based on 10 million users’ self-reported records from a smartphone application. Neurology 2023; 101: e2560-e2570.

This summary is taken from the following Journal Watch title: Neurology.